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Case Presentation

Detailed case study presenting patient demographics, medical and dental history, signs and symptoms, clinical and radiographic examinations, diagnosis, treatment plan, implementation, prognosis, and evaluation. Includes thorough assessment and discussion on factors influencing treatment outcomes.

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Case Presentation

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Presentation Transcript

  1. Case Presentation • Patient (demographics) • Medical History (general anamnesis) • Dental History & Chief Complaint (special anamnesis) • Examination (status presens) • Clinical examination • Radiographic examination • Diagnosis • Treatment plan • Treatment • Prognosis • Assessment and Evaluation

  2. Patient • Age • Gender • Race/ethnic origin • Referred by ? to whom or where? for what?

  3. Medical History • Systemic conditions that may produce or affect the patient’s symptoms • Drugs the patient is taking: identify possible adverse drug interactions • Systemic contraindications to treatment • Need for premedication and prophylaxis

  4. Dental History & Chief Complaint • What prompted the patient to consult a dentist in the first place (in the patient’s own words) • No diagnosis should be included at this stage • History of present illness/discomfort • An interview process during which the dentist attempts to evaluate the patient’s symptoms accurately, completely, and objectively, avoiding the temptation to make a premature diagnosis

  5. Dental History & Chief Complaint Open-ended, non-leading questions • ”Tell me about the problem” • ”I understand you have been experiencing cold sensitivity in your upper front teeth for several weeks, is that correct?”

  6. Dental History & Chief Complaint Specific questions about the nature of the symptoms experienced: • Inception (When the first time) • Frequency and cource (How often) • Intensity (Mild, moderate, or severe: medication, home from work) • Quality (Sharp, dull, stabbing, throbbing)

  7. Dental History & Chief Complaint • Location (Pointing to the tooth that hurts) • Provocation factors (heat, cold, momentary or last longer) • Spontaneous (without provocation)? • Attenuating factors (Anything relieving the pain

  8. Examination • Clinical examination • Extraoral examination • Intraoral examination • Documentation (photo) • Frontal view of dentition • Occlusal or lingual (for front teeth) view • Others as necessary for highlighting aspects • Radiographic examination • Dental periapical • Orthopantomogram in special cases • CT in special cases

  9. Intraoral examination • Any alterations of the color, texture, consistency, or contour of the soft tissue and should be noted • The tooth/teeth in question should be inspected for color changes, caries and restorative status • Palpation test • Percussion test • Mobility test • Periodontal examination: gentle probing

  10. Intraoral examination Thermal pulp tests: Cold test • Cold water bath in rubber dam basin • Ice sticks • Compressed gasses: ethyl chloride; 1,1,1,2 tetrafluoroethane (Endo-Ice) • Carbon dioxide snow

  11. Intraoral examination Thermal pulp tests: Heat test • Hot water bath in rubber dam basin • Warm gutta-percha

  12. Intraoral examination Electric pulp tests: • Electric excitation to stimulate the Aδ sensory fibers within the pulp • Does not provide any information about the health or integrity of the pulp; it simply indicates that there are vital sensory fibers present within the pulp

  13. Intraoral examination Special tests: • Crown removal for inspection • Selective anesthesia test • Test cavity for sensitivity • Transillumination for caries and physical defects

  14. Radiographic examination • Diagnostic radiography should be used only after the history is recorded and the clinical examination is accomplished Limitations • Provides a two-dimensional portrayal of a three-dimensional reality • Cannot be used to determine the status of the health and integrity of the pulp

  15. Diagnosis Pulpal andapical periodontal Other relevant: periodontal,prosthodontic

  16. Treatment plan • Short term and long term • Treatment • Immediate and permanent • Documentation (photo) • As necessary for highlighting aspects of treatment • Final: occlusal or lingual (for front teeth) view of restored tooth • Prognosis • Endodontic and dental • Success rate for the relevant diagnosis and treatment selected

  17. Discussion: Assessment and Evaluation • Assessment of the treatment outcome in this particular case • Reasons for making the diagnosis and treatment plan • Evaluation of the treatment chosen • Factors influencing the treatment outcome in this case • Was there any alternative treatment? And what would happen if another treatment had been chosen

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